New Client Form

for Adults
100%

Client information

Client information

(continued)

Primary Insurance Information

(If applicable as written on insurance card)

Secondary Insurance Information

(If applicable)

EAP

(If applicable)

I authorize the release of any medical or other information necessary to process an insurance claim. I understand that HCCC will diligently attempt to get accurate information regarding my mental health insurance benefits. I will not hold HCCC liable for insurance nonpayment due to misquoted benefits. I acknowledge I am responsible to know and understand my benefits plan. HCCC will not file my insurance claims for me as a courtesy. I am ultimately responsible for all charges my insurance company does not pay, except for contracted network provider discounts that may apply. I also request assigned benefits to be paid to HCCC and/or the provider indicated above.

Education & Work

Medical Information

Medical Information

(continued)

Emergency Contact Information

Legal Information

Spiritual Information

Be assured that our staff is very professional and will respect your belief and value system. We are trained at integrating our clinical skills with biblically sound approaches to life’s struggles. We will meet you where you are in your beliefs.

Alcohol/Drug History

Symptom History

Symptom History

Counseling Details

Counseling Details

(continued)

I agree that the information I have provided is accurate and true, to the best of my ability.

Permission for telemedicine

(when session is a telehealth session)

I consent to engage in telemedicine ( internet or telephone based therapy ) when agreed by me and my counselor to have a telemedicine session. I understand that telemedicine includes the practice of healthcare delivery, including mental health care delivery, diagnosis, consultation, treatment, transfer medical data, and education use an interactive audio, video, and/or data communications. The laws that protect the confidentiality of my medical information also apply to telemedicine. I understand that there are risks and consequences from telemedicine. These may include, but are not limited to, the possibility despite reasonable efforts on the part of my counselor that: that transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by an authorized person; and/or misunderstandings can more easily occur. In addition, I understand that telemedicine-based services and care may not have the same results nor be as complete as face-to-face service. Lastly, I understand that not all insurance plans cover telemedicine. I have read and understood the information provided above.

Appointment Cancellation Policy

At the very minimum, a twenty-four (24) hour notification is a required respect to the therapist who is reserving time for you and to other clients who are on a waitlist for appointments. You must give at least a 24-hour advance notification for cancelled or rescheduled appointments to avoid being charged the full session fee. To cancel or reschedule a Monday appointment, we kindly ask that this be done on Friday so that there is adequate time to allow the appointment to be filled by another client. This advance notice is standard in our profession.

HCCC has a 24 hour answering service that records time and date of your call to assist you in cancelling appointments in a timely manner.

Signature for Professional Services Agreement

I do voluntarily agree to participate in the assessment and counseling as offered by Houston Center for Christian Counseling and my selected therapist. I am aware that treatment often involves family therapy or education which will be recommended if the therapist deems it important to the healing process. I acknowledge that no guarantees have been made to me regarding the outcome of my therapy. I understand my rights and responsibilities as stated in the document.

I consent to the use of my personal health information for routine practices for treatment, payment, and health care operations according to the laws of the State of Texas and the Federal government as outlined in the Confidentiality section of this document and discussed in detail in the Confidentiality Policy and Privacy Practices informational form, which I have received.

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Sugar Land
(281) 277-8811